Benign tumors of the ovary - PowerPoint Presentation

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Benign tumors of the ovary

Assistant Prof

Fadia

Al-

Izzi

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Benign ovarian cysts are common, frequently asymptomatic &often resolve spontaneously

.

90%of all ovarian tumors are benign although this varies with age.

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Of the tumors that require surgery are:

1

) 13% in premenopausal women are malignant.2

) 45

% in post menopausal women are malignant.

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The main objectives of management

are:-

to exclude

malignancy

&to ovoid cysts accidents ,

without

causing undue morbidity or mortality or impairing future fertility for younger women

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Ovarian tumors may be physiological or pathological & may arise from any ovarian tissue.

Most benign ovarian tumors are cystic .The finding of solid elements makes malignancy

more likely; however; fibroma, thecoma,

dermoid

, Brenner tumor usually have solid elements.

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Physiological cysts: follicular cyst, corpus luteal cysts, theca luteal cyst

Benign germ cell tumors:

dermoid cyst, mature teratoma.Benign epithelial tumors: serous cyst adenoma, mucinous cyst adenoma, endometroid

cyst adenoma, Brenner s tumor, clear cell tumors.

Benign sex cord stromal tumors: granulose cell tumors, theca cell tumors, fibroma.

Sertoli – leyding

cell tumors.

F.Inflammatory

:

tubo- ovarian abscess , endometrioma. 

Pathology of benign ovarian tumors:-

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Physiological cysts:

Common cyst form during the normal ovarian cycle.

Most are asymptomatic & treatment is conservative.

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1) Follicular cyst:- it is the most common benign ovarian tumor and is most often found incidentally.

*It can persist for several MC & may reach diameter of up to 10 cm.

*Indication for surgery:-If symptoms developed. If the cyst doesn’t resolve after 8-16 weeks

.

*

Occasionally they may continue to produce estrogen causing menstrual disturbances & endometrial hyperplasia, since it is lined by granulose cells.

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2) Luteal cyst:-Less common than follicular cyst.

It is more than 3 cm in diameter.

It is more common on the right side.They may rupture (on day 20-26 day of the cycle)& present usually with intraperitoneal bleeding.

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Benign germ cell tumors:-

 

It is the commonest ovarian tumor seen in women less than 30 years age.2-3% is malignant only but this proportion increase to 1/3 if seen in women < 20 years age.Benign tumors are cystic but may have solid elements.

They are of 2 types:

dermoid

(mature cyst

teratoma)&mature solid teratoma.

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Common (account for around 40% of all ovarian neoplasm) & it is more in young women, the median age of presentation is 30 years.

It results from differentiation of embryonic tissues (mainly ectoderm).

Bilateral in 11% of cases.It is usually unilocular cyst.< 15 cm in diameter

1)

Dermoid

cyst (mature cyst

teratoma

):-

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Monodermal teratoma

is

teratoma with single type of tissue like:Primary carcinoid tumors of the ovary: give rise in 30% of cases to carcinoid symptoms% it rarely metastasize.Stuma

ovarii

tumors predominantly composed of thyroid tissue, it form about 1.4% of cystic

teratoma&only

5-6 %produce sufficient thyroid hormone to cause hyperthyroidism&5-10%of struma ovarii

develop into carcinoma.

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Complication:Torsion

2. Rupture leading to acute abdomen &chemical peritonitis. This complication is common during pregnancy.

3.2% contain malignancy (usually sequamous carcinoma) in women >40 years age. 

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Rare.Must be differentiated from immature

teratoma

which is malignant. 

2) Mature solid

teratoma:-

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The majority of ovarian neoplasia both benign &malignant arises from the ovarian surface epithelium.

They are therefore

mesothelial in nature derived from the coelamic epithelium overlying the embryonic gonadal ridge, from which develop mullerian

&

wolffian structures: therefore: this may result in development along:-

Benign epithelial tumors:-

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Endocervical=mucinous cyst adenoma.

Endometrial=

endometrioid.Tubal =serous cyst adenoma.Uroepithelial=Brenner.

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Serous cyst adenoma:-

It is the most common benign epithelial tumors.

Bilateral in 10% of cases.

Usually

unilocular

with

papilliferous processes on the inner surface & occasionally on the outer surface.

The epithelium on the inner surface is cuboidal or columnar & may be ciliated.

They contain thin & serous fluid.

They are seldom as large as mucinous tumors.

 

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Mucinous cyst adenoma:-

 

It is the 2nd most common epithelial ovarian tumor.It is typically large, unilateral, multilocular

cyst with smooth inner surface.

The lining epithelium consists of columnar mucus secreting cells, so the fluid is thick &glutinous.

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Endometroid cystadenoma

:-

Difficult to differentiate from ovarian endometriosis.

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Brenner tumor :-

Account for 1-2 % of all ovarian tumors.

Bilateral in 10-15 %

The majority is benign, but borderline or malignant

specimens have been reported.

75% occur in >40 years.

Majority are < 2 cm.

Some secrete estrogen causing AUB.

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Clear cell (mesonephroid) tumors:-

Rarely benign. 

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Benign sex cord stromal tumors

It represent only 4% of benign ovarian tumors

They occur at any age.Many secrete hormones &present with the results of inappropriate hormone effects.

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Granulose cell tumors:

malignant

but mentioned here because they are generally confined to the ovary so have good prognosis.

however

; they do grow very slowly & recurrences are often seen 10-20 years later.

They are large & solid.

Some produce estrogen or

inhibin

.

Call-

Exner bodies are pathognomonic but are seen in less than 50%.

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Theca cell tumors:-

Almost all are benign, solid & unilateral.

Present at 6th decade.Many produce estrogen causing precocious puberty,

postmenapausal

bleeding, endometrial hyperplasia & endometrial cancer.

They rarely cause

ascitis or plural effusion.

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Fibroma:-Hard, mobile, lobulated tumors.

Usually occur around 50 years age

<10% is bilateral.May be associated with ascitis

.

Meig

s syndrome (

ascitis & pleural effusion) is seen in only 1% of cases.

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Sertoli

-

Leyding cell tumor:- *These are of low grade malignancy.

*Most are found around 30 years of age.

*Rare (less than 0.2percent).

*Many produce androgen &some secrete estrogen.

*They are usually small &unilateral.

 

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Age distribution of ovarian tumors:_

In

younger females, the most common benign ovarian tumors Are germ cell tumor.

epithelial cell tumors more in older women

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Presentation

 

*Asymptomatic.*Pain (may result from tortion, rupture, hemorrhage or infection)

*Abdominal swelling.

*Pressure effect.

*Menstrual disturbance.

*Hormonal effect.

*Abnormal cervical smear.

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Differential diagnosis: _

 

A-PAIN *Entopic pregnancy.

*Abortion.

*PID.

*Appendicitis.

*Meckle’s diverticulum’s.

 

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-ABDOMINAL SWELLING

*Pregnant uterus.

*Fibroid.*Full bladder.*Distended bowel.*Ovarian malignancy.

*Colorectal carcinoma.

*Lymphoma.

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PRESSURE EFFECT:-

*UTI. *Constipation. D-HORMONAL EFFECT:-

*All other causes of menstrual cycle disturbance.

*Precocious puberty and PMB.

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 E

.present

by complication :Hemorrhage. Rupture .

Infection.

Torsion :

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Torsion :

Ovarian or

adenxial torsion is an infrequent but significant cause of acute lower abdominal pain in women. this condition is associated with reduced venous return from the ovary as a result of stromal edema , internal hemorrhage, hyperstimulation , or a

mass.the

ovary and fallopian tube are typically involved.

A quick and confident diagnosis is required to save the

adenxal structures from infarctin.

Ultrasonography with color Doppler is the method of choice for the diagnosis.

Treatment :operation (

laprotomy

or laparoscopy) is the treatment of choice.

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Investigations:-

*

The investigations required will depend upon the circumstances of the presentation.*Patients presented with acute symptoms will usually need emergency laprotomy while asymptomatic patient or those with chronic problem may benefit from more detailed preliminary assessment.

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Full history

*Family history of ovarian, bowel, breast) cancers.

*Indigestion or dysphagia might indicate a primary gastric cancer metastasizing to the pelvic organs.*History of altered bowel motion or rectal bleeding would suggest diverticulosis or rectal cancer.

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2) Examination (general, abdominal, obstetric), searching for features go with malignancy.

*Acute emergency look for tachycardia, cold

peripheries&signs of hypovolemia.

*Breast, neck, axillary lymph node examination. *Pleural effusion goes with malignancy.

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3)Ultrasound:-

Transvaginal or transabdominal.

Detection

of ovarian mass.

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*Features go with malignant ovarian tumors:-

-Solid tumor.

-Bilateral tumor. -Free fluid in peritoneal cavity. -Involvement of lymph nodes.

-Increased vascularity by color Doppler.

-Large tumor.>10 cm.

 

 

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Other investigations :-*CXR.:-metastasis or pleural effusion.

*Abdominal X-ray:- calcifications in benign

teratoma.*Ba. Meal: - if symptoms or suspicion of GIT malignancy.

*Complete blood

film&count.

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Serum markers:

-CA125 is strongly suggestive of ovarian carcinoma; especially in postmenopausal women (may increase in endometriosis).

-Measurement of B-HCG. In suspicion of ectopic pregnancy. But trophoblastic tumors and some germ cell tumors secrete this marker.

-Estradiol may increase in follicular cyst and sex cord stromal tumor.

-Androgen may be increased in

sertoli-leydig

tumors.

-Increased alpha

feto

protein suggests yolk sac tumor.

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Management:-

 

It depends on:-Age.-Symptoms.-Plan for further pregnancy.

 

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Older women:-

-Women over 50 years of age are far more likely to have malignancy and have little to gain from conservative management

-Pelvic mass >5cm :-physiological cysts are unlikely but still there is 17% chance possibly of benign tumors in which 50%will resolve spontaneously

A-Asymptomatic patient:-

 

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29-50%of all ov. Cysts will be malignant in postmenopausal women.

-Therefore efforts have been made to define criteria that would enable unnecessary surgery to be avoided in older age group .

It is recommended that the( risk of malignancy index RMI)should be used to select those women who require surgery .

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RMI = U * M *CA125.

According to this patient are classified into

: Low risk : score < 25.Moderate: score 25 -250.High : score > 250.

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A) Tumor marker CA125<35MU/ml

B) Ultrasound:-simple, unilateral, less than 6cm. C) Color flow Doppler shows normal vascular resistance. 

Examples of low

risk :

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If all three criteria present then the ovarian cyst are likely to be benign &may be managed conservatively.

If there is no change in the cyst in the second ultrasound at three months follow up with six months ultrasound &CA125 estimation is safe.The role of laparoscopic surgery in the assessment &treatment of apparently benign cysts in this age group is controversial

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Premenapausal

women:-

-<35 years are both more likely to wish having the option of further children and less likely to have a malignant epithelial tumor. -A clear unilateral cyst of (3-10cm) identified by ultrasound should be re-examined 12 weeks later for evidence of decrease in size. If present, follow up by US. &CA125 for 6 months. If increased in size,

laproscopy

or laprotomy

may be indicated.

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-Unilateral-

Unilocular

cyst without solid elements.-Premenapausal women, tumor (3-10cm).-Postmenopausal women, tumor(2-6cm).

-Normal CA125.

-No free fluid or masses suggesting

omental

seed or matted bowel loop.

Criteria for observation of asymptomatic ovarian tumor:-

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Severe abdominal pain or sign of

intraabdominal

bleeding then do emergency laprotomy or laparoscopychronic

symptoms. Do investigations.

Surgery

: include:-

*Ovarian cystectomy. *

Oophrectomy

.

*

Adenectomy. 

B-Patient with symptoms:-

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Increase incidence of complication (torsion, bleeding,…).May prevent the presenting fetal part from engagement.

May discover incidentally during U/S or C/S.

Pregnant women

with ovarian tumors

 

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No place to postponed operation if acute abdomen.If asymptomatic, it is wise to wait until 14 weeks gestation before removing it to ovoid the risk of removing a corpus luteal cyst.

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If cyst unresolved 6 week postpartum, surgery is undertaken. Ovarian cancer is uncommon during pregnancy, occurring in less than 3% of cyst. However, a cyst with features suggestive of malignancy on ultrasound, or one that is growing, should be removed surgically.

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CA 125 is not useful in pregnancy since it can be elevated normally.Management may need to include a Caesarean hysterectomy, bilateral

salpingo-oophorectomy&omentectomy

.

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